The Computerized Patient Record, the Electronic Medical Record and now the Electronic Health Record—do we really need another acronym? EHR’s arrival in the literature reflects a shift in emphasis toward a more integrated health record, said Lloyd Hildebrand, MD, who chairs the Academy’s committee on Medical Information Technology. The term “health” implies that a patient has an ongoing, longitudinal record that draws together data from all of his or her providers.

This more expansive vision of the paperless office would, according to its proponents, improve quality of care while reining in medical cost inflation. Not surprisingly, this prospect of “more for less” has found a receptive audience in Washington, D.C., where bipartisan committees in both the House and Senate have rallied behind the concept of the EHR. And in 2004, President Bush asked National Health Information Technology Coordinator David Brailer, MD, PhD, to develop a strategic plan that would give most Americans access to an EHR within 10 years. It is proposed that a national health information network would use the Internet to link the information systems of physicians, hospitals and public health agencies.

Two Short-Term GoalsThis ambitious undertaking may ultimately have a big impact on the ophthalmic practice of 2014—but what about the practitioner of today? Dr. Brailer has identified short-term goals that he regards as foundational building blocks for his long-term plan. Two of his early priorities are of particular interest to the practicing ophthalmologist.

First, the disparate information systems of different providers must be able to seamlessly exchange information with one another, and then put that information to use—this is known as interoperability. “It entails more than sharing a PDF file,” said Dr. Hildebrand. “Systems need to share the context of the information.” To achieve this, a framework of standards is needed.

Second, Dr. Brailer wants computerization of records to become more commonplace in clinical settings, and he is particularly keen to increase use of EHRs in smaller-sized practices.

Goal 1: Interoperability“Standards are key to achieving efficient interoperability,” said Dr. Hildebrand. “And the big three are DICOM, SNO-MED and HL7.”

DICOM provides standards for medical images. The Digital Imaging and Communications in Medicine standards are crucial for ophthalmology because so much of what the profession does relies on visual inspection.

HL7 provides standards for data management. The Department of Health and Human Services asked Health Level 7—an international standards-setting organization—to define all the functions that an electronic health record might need. Last year, HL7 published the Electronic Health Record System (EHR-S) Functional Model as a tentative standard for trial use. This provides a standard reference list of 125 possible EHR functions. Each specialty can then draw on this to compile a sub list of functions—known as a Minimum Function Set—which a practice in that field would need in its EHR system. Last spring, the Academy sought feedback on a Minimum Function Set for Ophthalmology. It hopes to publish the results early next year.

The next step—software certification. We currently need a more “standardized” approach to standards, said Dr. Hildebrand. For instance, two vendors may both claim to be DICOM-compliant, but that doesn’t guarantee that the first vendor implements the DICOM standards in a way that is compatible with the second vendor’s implementation of those same standards. In an attempt to address this problem, several providers, payers and vendors formed the Certification Commission for Healthcare Information Technology last fall. CCHIT is now well on its way to developing a certification process for EHR products, said Dr. Hildebrand.

Goal 2: Promoting EHR UseDo the benefits of EHRs outweigh the expense and disruption of implementing them? Judging by the low rate of EHR-adoption, many small- and medium-sized practices seem skeptical that going paperless will yield a positive return on investment. Dr. Brailer has acknowledged this and is exploring ways to reduce the risks and boost the benefits of EHR adoption.

Certification and the continued development of standards would, it is hoped, reduce the risk—particularly for practices that lack the expertise to be confident about their choice of vendor. Standards may also improve EHR efficiency by, for instance, forcing vendors to compete on issues of usability, such as the convenience of the user interface.

Several incentive options were suggested in a report that the Department of Health and Human Services published last year. These ranged from new reimbursement codes and pay for performance programs that would reward clinicians for use of EHRs, to low-rate loans that would help practices go paperless. But to date, “there has been a lot of debate and little action,” said Dr. Hildebrand. “The question is—‘Who’s going to pay for it?’”

Seeking a ConsensusThe government has offered a vision of where it wants EHRs to be in 2014, but it is urging health care’s stakeholders to determine how to get there. This has sparked much discussion over the last 18 months. The parties to this debate include:

The Interoperability Consortium. In August 2004, eight leading technology companies—including Cisco Systems, IBM, Intel, Microsoft and Oracle —came together to provide feedback on the national health information network that Dr. Brailer had proposed. They recommended that the network’s architecture be based on nonproprietary standards.

The Physicians’ Electronic Health Record Coalition. In June 2004, the American Medical Association and 14 specialty societies launched PEHRC. The coalition represents more than 500,000 U.S. physicians.

The Academy. “We have been taking a logical approach with respect to the things that need to evolve,” said Dr. Hildebrand. The Academy staffs the secretariat of DICOM Working Group 9, is on the SNOMED editorial board and is working on an HL7 Minimum Function Set—which means ophthalmology will be well-placed to take advantage of EHR software that integrates across different networks. And as a founder-member of PEHRC, the Academy is ensuring that ophthalmology has a say in the national debate on EHRs.

The American Health Information Community. In mid-July 2005, the Department of Health and Human Services called for nominations for this public-private collaboration. Nine of its members are to come from the public sector and eight from the private sector. It will provide a forum for public and private interests to recommend actions that will accelerate the widespread application and adoption of EHRs.

Vendors with experience overseas. The U.K.’s National Health Service is “developing an overarching I.T. backbone for its health care system,” said Dr. Hildebrand. “There are a lot of vendors that are common to both sides of the Atlantic, and they’re learning very valuable lessons from what is happening in the United Kingdom.”

Today’s MarketplaceIf you plan to computerize your patient records, Dr. Hildebrand warns that there is currently a lot of consolidation among vendors, “and that makes it important to evaluate a vendor’s longevity risk. You should also find out what would happen if there is a change of control at that company.”

He also stressed that you should evaluate a vendor’s commitment to the three main standards—DICOM, SNOMED and HL7.

Annual Meeting Presentations

This year’s Annual Meeting features several presentations where you can learn more about computerizing your office. For ticketed events, you can take advantage of the advance rate if you buy your tickets online no later than Sept. 28. For more information on these presentations, or to buy tickets, visit www.aao.org/meetings/annual_meeting.

7:30 to 8 a.m.Electronic Medical Records: Techniques of Practices that Have Made the Transition SuccessfullyDavid E. Silverstone, MD(Breakfast with the Expert B306—advance fee is $30; onsite fee is $40.)

9 to 10 a.m.Understanding the Electronic Medical Record: An Overview of Modern EMR Applications from Evaluation and Purchase to Implementation and ScalabilityRamana S. Moorthy, MD(Instruction Course 348—advance fee is $25; onsite fee is $35.)

11:30 a.m. to 12:30 p.m.Electronic Medical Record Panel Discussion: Should You Implement EMR Now, and How Do You Make the Transition Successful?Moderator: Susan E. Jones(Instruction Course 610—advance fee is $25; onsite fee is $35.)